“Zichtbare schakel: De dorpsverpleegkundige in Menterwolde”

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A better link between housing, welfare, and

healthcare at district level

“Zichtbare schakel: De dorpsverpleegkundige in Menterwolde”

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Robert F. Kroes Page 2 of 66

A better link between housing, welfare, and

healthcare at district level

“Zichtbare schakel: De dorpsverpleegkundige in Menterwolde”

By

ROBERT FRANK KROES

Supervisors University: H.G. (Henk) Sol R.A. (Robert) Rozier

Supervisors Company A. (Anneke) de Vries G. (Gepke) Scheringa

University of Groningen Faculty of Economics and Business

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Preface

This research report, which lies in front of you, serves as my master‟s thesis which marks the end of my study Technology Management.

I started my master‟s research in April 2011, after a meeting with Henk Sol and Gepke Scheringa in Veendam. They had a project at hand in which I could participate by doing research for my master thesis. This research meant that I needed to find out what kind of role the community nurse plays within the municipality of Menterwolde and more specific what her role is within an integrated team of professionals that take care of the healthcare, welfare and wellbeing of elderly in Menterwolde. I hope that the results of this master‟s can increase the success of the project “Zichtbare schakel: De dorpsverpleegkundige in Menterwolde. I also hope that the results and the way I reached it can help me in my further career.

This report starts with an introduction of Menterwolde, the project “Zichtbare schakel”, and the community nurse. In the second chapter the research and sub questions are defined. Chapter three discusses the research approach and the validity of this research. In the fourth chapter a background is provided to the research question and also in this chapter a conceptual model is constructed. The analysis starts in chapter five. This paper will end with a conclusion and some recommendations for further research.

I would like to thank all my supervisors that have guided me during this research. I also want to thank my family for their support during this project and during my study Technology Management.

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Management Summary

The coming years the region of East Groningen and especially the municipality Menterwolde has to deal with an increasingly ageing population and with the fact that the number of facilities provided in small villages are decreasing. One of the challenges that comes along with ageing is that healthcare consumption will increase. Looking at the current developments of the healthcare system in the Netherlands, the municipality of Menterwolde will have to prepare itself for its responsibility to provide inhabitants the opportunity to stay in their own environment as long as possible.

To cope with this perspective, the project “Zichtbare schakel: De dorpsverpleegkundige in Menterwolde” is launched. The goal of this project is to increase the welfare, wellbeing, and living conditions of the elderly, by deploying a community nurse and the establishing of an integrated collaboration between welfare, housing, and healthcare providers. The community nurse will play an important central role in this integrated collaboration, therefore the tasks of a community nurse are different than that of a regular visiting nurse. The new tasks include:

 Coordinate assistance to individuals by bringing individuals in contact with organizations of the integrated collaboration.

 Early identification of non-indicated requests for help.

 Coaching and guiding the vulnerable elderly with welfare, housing, healthcare, and opportunities of domestical technology with the ideology of “What the elderly can still do by themselves, the elderly must be able to do by themselves”.

To find out whether the project “Zichtbare schakel” will lead to success so that the municipality Menterwolde can deal with its future, the following research question is formulated:

Does the project “Zichtbare schakel: De dorpsverpleegkundige in Menterwolde”, with its community nurse and the establishment of an integrated

collaboration between welfare, housing, and healthcare providers, increases the efficiency and effectiveness of welfare, housing, and healthcare services

for the vulnerable elderly?

Within the main research question, efficiency means that the new situation requires fewer resources than the old situation. In this research this means that cost of welfare, housing, and healthcare services are reduced by using a community nurse and establishing an integrated collaboration between welfare, housing, and healthcare providers. Effectiveness means whether it is possible to keep vulnerable elderly longer in their own environment by using a community nurse and an integrated collaboration between welfare, housing, and healthcare providers.

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Robert F. Kroes Page 5 of 66 care. This will lead to a shift in responsibilities, tasks, and services from professional care to informal care. This way costs can be saved on the professional care because this kind of care will be minimized. Based on the scenario analysis conducted in this research, also costs on the social support act (WMO) can be reduced when the level of informal care increases. This is due to the fact that the number of new WMO applications will decrease. A decrease in new WMO applications will also lead to less work for the WMO consultant. In addition, the community nurse can take over all the tasks of the WMO consultant because the community nurse also gives an indication on what kind of professional help a client needs. This can also mean that she can decide whether or not a WMO application is needed. When this is realized, it will lead to the termination of the WMO consultant which will cause a costs saving of approximately € 50.000 a year.

When the amount of informal care is higher, this will lead to a reduction of up to 75% new WMO applications. The total amount that will be saved when this is the case can be up to € 250.000 a year. When the level of new applications cannot be reduced with more than 25%, the costs of the project would not be covered which would lead to project failure. Therefore it is very important that the level of informal care increases.

When the project “Zichtbare schakel” ends the project team hopes to find new cash flows that will pay for the community nurse. The termination of the WMO consultant and the cost saving on the WMO budget should lead to the possibility that the municipality Menterwolde takes over the control and responsibility of the community nurse. When this is accomplished, the community nurse will have a completely neutral position because the municipality is not interested in which provider is used. They only want to establish a situation that makes it possible the keep elderly people in their own environment as long as possible.

Not only the municipality will benefit from the project “Zichtbare schakel”, also general practitioners can benefit because the community nurse could take over house visits which are currently the responsibility of general practitioners. This will save time and money which the general practitioners can spend otherwise.

Looking at the findings concerning the effectiveness, it can be concluded that the use of a community nurse will increase the independence of people. Also, it will create a more safe and secure environment for people because of the visible presence of the community nurse and the fact that people know where they can go to when they have problems. Another important point is that social relations stay intact, which helps to promote the use of informal care and the overall health and welfare of the people. Next to this, there will be shorter communication lines due to the use of an integrated collaboration. This will lead to an improvement in effectiveness, because appropriate actions can be taken much quicker which gives clients a better feeling of wellbeing.

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Robert F. Kroes Page 6 of 66 visited by the community nurse, the number of households that are visited, results of the prevention interventions, the number of WMO applications and the ratio between the number of care indications and the number of ageing people in Menterwolde.

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1.5 Initial Motive ... 11 1.6 Research Goal ... 12 2 Problem definition ... 12 2.1 Research Question ... 12 2.2 Sub-Questions ... 14 2.3 Constraints ... 14 3 Research approach... 15 4 Background ... 16 4.1 Self-reliant ... 16 4.2 Integrated collaboration ... 16 4.3 Communication ... 17 4.4 Project monitoring ... 18 4.5 Conceptual Model ... 18 5 Analysis ... 20

5.1 The current situation ... 20

5.2 Community nurse ... 22

5.3 Integrated collaboration of welfare, housing and healthcare ... 28

5.4 Monitoring the project ... 30

6 Results of this study ... 37

6.1 Conclusion ... 37

6.2 Discussion ... 39

6.3 Future research ... 39

References ... 40

Appendix I Expected results of the project ... 44

Appendix II Nulmeting ... 45

Appendix III Interview... 63

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Glossary

Glossary

Community nurse Dorpsverpleegkundige

Informal care Diensten die worden geleverd door mantelzorg of vrijwilligers.

KPI Key Performance Indicator

MD Management dashboard

MIS Management informatie systeem

Primary care Eerstelijnsgezonheids zorg.

De eerstelijnszorg, is zorg waar een cliënt zonder verwijzing en op eigen initiatief naartoe kan gaan. Bijvoorbeeld de huisarts, tandarts, fysiotherapeut of verloskundige. Maar ook een maatschappelijk werker of een psycholoog valt hieronder (Rijksoverheid, 2011).

Professional care Diensten geleverd door een van de partijen van woon, welzijn en zorg in Menterwolde.

Public Health Service Gemeenschappelijke gezondheidsdienst (GGD).

De GGD is een organisatie die de (volks)gezondheid beschermt, bewaakt en bevordert (GGD, 2011).

Secondary care Tweedelijnsgezondheids zorg.

Tweedelijnszorg bestaat uit ziekenhuizen en geestelijke gezondheidszorg. Toegang tot deze zorg krijgt u alleen na verwijzing van een zorgverlener uit de eerstelijnszorg (Rijksoverheid, 2011)

Socioeconomic status Sociale Economische Status (SES).

De SES geeft iemands plaats aan op de maatschappelijke ladder gezien vanuit een sociaal en economisch economische status welke o.a. bepaald wordt opleidingsniveau, beroep of inkomen.

Village Advisory Council DorpsAdvies Raad (DAR). Vulnerable elderly Kwetsbare ouderen.

In het kader van dit onderzoek zijn kwetsbare ouderen gedefinieerd als personen van 65 jaar of ouder (NPO, 2011; Slaets, 2006) en welke te maken hebben met psychosociale en medische problemen waardoor ze afhankelijk worden van zorg en ondersteuning (Slaets, 2006).

Visiting nurse Wijkverpleegkundige.

Welfare Foundation Stichting welzijn Menterwolde (SWM).

Stichting Welzijn Menterwolde, is een brede welzijnsorganisatie voor de gemeente Menterwolde. De stichting is verantwoordelijk voor de uitvoering van: Peuterspeelzaal werk, ouderenwerk, algemeen maatschappelijk werk, project nieuwkomers en dorpsteunpunten (Scheringa, 2010).

WMO De Wet Maatschapelijke Ondersteuning (WMO).

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Introduction

1 Introduction

This chapter will give short introductions of the municipality Menterwolde, the project “Zichtbare schakel” and the community nurse (dorpsverpleegkundige) and it will define the terms vulnerable elderly people, professional care and informal care. After this the research goal will be discussed.

1.1 The municipality Menterwolde

The municipality Menterwolde which is located in East Groningen was created on January 1st, of 1990. On this date the municipalities Meeden, Muntendam, and Oosterbroek merged, as a result of municipal reorganization. The current municipality Menterwolde includes the villages Muntendam, Meeden, Noordbroek, Zuidbroek, Tripscompagnie, and part of Borgercompagnie.

The municipality Menterwolde has approximately 12.500 inhabitants, which are spread over 5,264 households. Table 1 shows the number of people in Menterwolde that are 65 years or older.

Aging category Population (2010) Percentage in % of total inhabitants (2010)

65 -74 year 1.095 8,8

75 - 84 year 500 4,0

85+ year 185 1,5

Total 65+ year 1.780 14,3

Table 1: People of 65+ years in Menterwolde (Menterwolde in cijfers, 2011)

According to the WMO monitor of the municipality Menterwolde, the number of elderly people that live alone will grow with 20% to 607 in 2020 (see Table 2). The result of an increase in the number of elderly that live alone is that the demand for support and the use of facilities will increase (Kuiper et al., 2010).

Age category 2007 2020 Growth rate

65 to 74 year 206 285 39%

75 to 85 year 224 252 12%

85 + 70 77 10%

Total 507 607 20%

Table 2: Prospect of elderly living alone

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Introduction

 Between 2010 and 2030 the number of people aged over 75 years will increase with 124.2%. The Public Health Service (GGD) stated that a rise in average age will cause an increase in health care consumption.

 In 2006 the social cohesion in Menterwolde was lower than the average in the province of Groningen. This means that care is mostly provided by professionals and less by informal care.

 In 2006, 70% of households in the municipality Menterwolde where located in an area with a low socioeconomic status (SES). People with a low SES seem to have more health problems than people with a high SES.

 A prospect until 2020 is that people over 65 years will have more physical disability (80%) and also the number of elderly people that live alone will increase (20%). This will cause a growing health care consumption for the future.

1.2 The project “zichtbare schakel”

The project "Zichtbare schakel: De dorpsverpleegkundige in Menterwolde” is launched to make sure that the municipality of Menterwolde is prepared for the future meaning that vulnerable elderly in Menterwolde can live in their home environment as long as possible.

Since 2003, a multifunctional center (De Gilde) is located in Muntendam. In this center several organizations, NOVO, zorggroep Meander and De Zijlen, housing corporation Het Groninger Huis, Welfare Foundation Menterwolde (SWM), several kindergartens and the steunpunt Muntendam, are working together. The “Zichtbare schakel” project is guided by the experience gained from the collaboration between the different partners in “De Gilde”. The goal is to use an integrated collaboration of welfare, housing, and healthcare in order to offer support to the vulnerable elderly in the municipality Menterwolde. Also the project tries to establish a central person that will be a clear and identifiable contact point for the different welfare, housing, healthcare providers in the integrated collaboration and the inhabitants of Menterwolde. This should keep Menterwolde livable and accessible for people with disabilities related to ageing. The community nurse will play a central role between the integrate collaboration and the vulnerable elderly. The tasks of a community nurse are different than that of a regular visiting nurse, because the community nurse has a more managerial task which includes (Scheringa, 2011):

 Coordinate assistance to individuals by bringing individuals in contact with organizations from the integrated health care network.

 Early identification of non-indicated requests for help.

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Introduction

1.3 Vulnerable Elderly

Most elderly people feel healthy and happy. Unfortunately not everyone is in good health and some of the elderly have become dependent on care and support. The transition between these two groups form the vulnerable elderly. At first they seem to be fairly healthy, but small physical and psychosocial problems are piling up, so eventually help from outside is needed (Campen, 2011). Vulnerable elderly can have psychosocial problems which involve two types of problems, namely mental problems and social problems (Dutch College of General Practitioners, 2007). The “Nationaal Programma Ouderenzorg”, defines vulnerability in two ways: The first way is the risk of losing functionality (chronic) caused by a disease. This loss of functionality decreases the ability to control life itself, mobility, moving independently, doing work around the house, personal care, and more. The second way is the risk of decreased self-reliance by the combination of long term health problems with a low income, poor living conditions and a weak social network. The ability to lead an independent life will then be more problematic. Based on this, vulnerability is not a disease but a condition, and an important recognition is that this state can be partly influenced. For example by helping older people to cope with their illness or limitations, or by supporting them to participate in the society (NPO, 2010)

1.4 Professional vs. formal care

Kemper (1992), mentions in his article that vulnerable elderly who live in their own home in their own environment and need help with basic activities as cooking, bathing, or eating can rely on care purchased in the formal market (professional care) or on care provided informally by family and friends (informal care) or on both. He also mentions that the amount of professional and informal care used, depends on five factors. First, when the need for care is high, it will be more likely that both professional and informal care will be necessary. Second, when the cost for professional care is high, it will be an incentive for a client to use informal care more frequently. Third, when the income of the vulnerable elderly is relative high, they will use professional care more often. Fourth, a higher availability of family leads to the use of less professional care and more informal care. Finally you have to deal with a person‟s personal preference.

1.5 Initial Motive

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Problem definition

 One contact point for vulnerable elderly people regarding housing, welfare, and healthcare.

 The vulnerable elderly will experience a seamless supply of housing, welfare, and healthcare.

 Increasing the self-reliance by encouraging and coaching vulnerable elderly and informal care possibilities.

1.6 Research Goal

With the project "Zichtbare schakel”, Menterwolde wants to prepared itself for the future and to find a solution so that the vulnerable elderly in Menterwolde can stay in their own environment as long as possible. The project tries to establish an integrated collaboration between welfare, housing, and healthcare and it will deploy a community nurse, which will play a central role between the integrated collaboration and the vulnerable elderly in Menterwolde.

The goal of this research is to find out whether the deployment of a community nurse and establishing an integrated collaboration between welfare, housing, and healthcare providers, in Menterwolde, can increase the efficiency and effectiveness of welfare, housing, and healthcare services for vulnerable elderly people in Menterwolde. Efficiency means that the new situation requires fewer resources than the old situation. In this research this means that cost of welfare, housing, and healthcare services are reduced by the deployment of the community nurse and having an integrated collaboration between welfare, housing, and healthcare providers. The effectiveness means that it is possible to keep the vulnerable elderly in their own environment longer by deploying a community nurse and creating an integrated collaboration between welfare, housing, and healthcare providers.

2 Problem definition

This chapter will first define the main research question. The second section will take this research question as input and convert it into sub-questions, which will be the starting point for this research. The third section contains the constraints that belong to this research.

2.1 Research Question

To provide the project “Zichtbare schakel: De dorpsverpleegkundige in Menterwolde” with advice, the following research question is formulated:

Does the project “Zichtbare schakel: De dorpsverpleegkundige in Menterwolde”, with its community nurse and the establishment of an integrated collaboration between welfare, housing, and healthcare providers, increase the efficiency and effectiveness

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Community nurse:

The community nurse plays a central role between the welfare, healthcare and housing service providers and the vulnerable elderly. The community nurse needs to locate the vulnerable elderly which can be done in several ways. It is possible that the community nurse visits older people, reacts on questions from the inhabitants of the municipality Menterwolde, talks with village advisory councils or talks to the general practitioners. When vulnerable elderly are located and the problems are clear, the community nurse can bring the vulnerable elderly in contact with suitable help and support. The community nurse will coach, help and guide elderly people with the ideology “What the elderly can still do by themselves they must be able to do themselves”.

Integrated collaboration between welfare, housing, and healthcare services:

Integrated (health) care, is often referred to as interdisciplinary healthcare, and is an approach characterized by a high degree of collaboration and communication among health and welfare professionals. What makes integrated healthcare unique is the sharing of information among team members related to patient care and the establishment of a comprehensive treatment plan. The benefits of an integrated healthcare approach extend to patients, caregivers, providers, and in the end the healthcare system. For instance, research indicates that integrated health care is effective in reducing depressive symptoms. Further evidence suggests that coordinated care can enhance access to services, improve quality of care and lower overall healthcare expenditures (American Psychological Association, 2011).

Efficiency:

Efficiency means that the cost of welfare, housing, and healthcare services for vulnerable elderly people are reduced by the deployment of the community nurse and an integrated collaboration between welfare, housing, and healthcare providers.

Effectiveness:

The effectiveness means whether it is possible to keep elderly longer in their home environment by deploying a community nurse and providing an integrated collaboration between welfare, housing and healthcare providers.

Welfare, housing, and healthcare services:

The community nurse will coordinate assistance to individuals, by bringing individuals in contact with welfare, housing, and healthcare providers from the integrated collaboration. The service that will be given to a vulnerable elderly can be realized by professional care (organizations) or by informal care (family or volunteers) or by both. The community nurse is the person who decides which kind of service is suitable.

Vulnerable elderly:

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2.2 Sub-Questions

This section will provide a more detailed direction to this research by defining questions. These sub-questions will help to answer the research question.

The sub-questions are:

Sub-question 1: How does the efficiency and effectiveness of welfare, housing and healthcare services increase, for the vulnerable elderly, by deploying a community nurse?

Sub-question 2: How does the efficiency and effectiveness of welfare, housing and healthcare services increase, for vulnerable elderly people, by establishing an integrated collaboration between welfare, housing, and healthcare providers?

Sub-question 3: How should the project be monitored, to establish a control mechanism for the project?

2.3 Constraints

To answer the main question, some constraints need to be taken in account:

1. Individual elderly and general practitioners in Menterwolde are not involved in this research, because Meander does not want to burden them with all kinds of research. Instead of interviewing the individual elderly, village councilors have been interviewed because they know what happens in the different villages of Menterwolde.

2. The municipality of Menterwolde does not want to cooperate with this research, because of political reasons.

3. Only organizations in de Gilde that are involved in the project “Zichtbare schakel” will be interviewed. This constraint is necessary, because within the Gilde there are some organizations that have nothing to do with elderly for example a kindergarten.

4. Keep in mind that the community nurse will act with the following ideology: “What the elderly can still do by themselves, they should be able to do by themselves”.

5. Monitoring the project ”Zichtbare schakel” will only be done during the grant period of 26 months. After this period it is not clear who will be responsibility for the community nurse. This can imply that the monitoring system needs to be redesigned to a new situation.

6. The tool to monitor the project will only be designed in theory.

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Research approach

3 Research approach

In this section the methodology for this research is described. To answer the main- and sub-questions three information sources have been used. First, information from scientific research has been used. Second, results of similar projects have been analyzed and third, interviews have been done with involved persons and organizations. These interviews will help to gain a clearer view of the current and goal situation. By using these three data sources it will be possible to provide a pluralistic overview.

Scientific information is obtained from relevant literature and is discussed in chapter four. Main criteria for the literature were that it is applicable to the community nurse in her central role between clients and service providers and to the establishment of an integrated collaboration between welfare, housing, and healthcare providers. Furthermore, the search for literature was guided by the sub-questions that were defined in the previous chapter.

This research will also look at other projects which use the same concept as the project “Zichtbare schakel”. In the Netherlands, similar projects that provide a community nurse have already been done. The conclusions and results of these projects could be applicable to the project “Zichtbare schakel”, therefore these findings will also be used.

The goal of the first visit to Zorggroep Meander was to define the main research question, but also to get a first impression. During several other visits to Menterwolde 12 interviews were conducted. These interviews were semi-structured and had the following three goals; first, discuss the most important issues regarding the community nurse, second, the cooperation between the different parties, and third, how the community nurse could increase the efficiency and effectiveness of housing, welfare, and healthcare services for the vulnerable elderly in Menterwolde. Interviewing different people about the same subjects has resulted in a multi-perspective to the collaboration between parties and the possibilities regarding the community nurse. Moreover, the risk of reliability errors is minimized because information is checked more than once. The interviews were conducted with people from the following functions:

 Project leader

 Project spokesman

 Zorggroep Meander (location manager the Gilde)

 Village Advisory Council Meeden

 Two community nurses in Menterwolde

 De Zijlen (manager of the region Veendam)

 Housing corporation Groninger Huis ( CEO)

 Stichting Welzijn Menterwolde (CEO)

 ZonMW specialist project “Zichtbare schakel”

 Customer Service Meander

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Background

Robert F. Kroes Page 16 of 66 The choice to interview people in these functions was based on the fact that these people all knew the project “Zichtbare schakel” and that they had a good overview of the situation. For the interviews three viewpoints are missing which are the mantelzorg coordinator, which could probably give more information about the current situation of informal care and about the current state of prevention interventions, the chairman of the project committee “Zichtbare schakel” and the municipality of Menterwolde, because they did not want to contribute to this research.

The interviews were all based on the same structure which can be seen in appendix III. First general information was obtained about the person that was interviewed. Second the interview looked at the vulnerable elderly people in Menterwolde. After this, the third part of the interview focused on the current collaboration between welfare, housing, and healthcare providers. This part also focused on the advantages and disadvantages of the current situation. After this, the fourth part of the interview focused on the possibilities of the community nurse and how the current situation could be influenced. The fifth part of the interview focused on how people want to monitor the project and which performance indicators they want to have. Finally the interview focused on the primary and secondary care provided in Menterwolde and how the project “Zichtbare schakel” could influence this.

4 Background

This section will provide a background of the problem, based on literature. In the final section of this chapter a conceptual model is constructed.

4.1 Self-reliant

People want to stay as long as possible in their own home, because they prefer not leave their familiar environment. Another point is that it is difficult for people to admit that they need help. When problems are recognized in an early stage, people can live longer in their own environment, which is not only pleasant for the elderly but it is also good for the (healthcare)budgets of the government (Kemper, 1992). Woittiez, et al (2009) agree with this, they mention that when people can stay in their own home longer, people experience a higher level of welfare and wellbeing (only when people want to stay in their own home), which result in a better personal health which in the end can reduce costs.

4.2 Integrated collaboration

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Background

Robert F. Kroes Page 17 of 66 without cooperation. Relations between people working in these cooperation‟s, should be created at all levels of a complex system. Therefore communication is important, but the need of frequent communication between different system units can be reduced by agreements on specific administrative activities and standardization or guidelines. Also several IT-systems can be used to facilitate the integration (Grazyna & Karlberg, 2000).

Groups and teams generally pass through a standardized sequence in their evolution, which can be described with the five stage group development model of Tuckman. This model characterizes groups as proceeding through five distinct stages: forming, storming, norming, performing and adjourning (Robbins & Judge, 2010).

 Forming The group comes together and initially they get to know each other. This way they will start to form a group.

 Storming Members accept the group, but there is resistance and a struggle about leadership and group processes.

 Norming Eventually an agreement is reached on how the group operates.

 Performing The group fulfills its tasks and becomes effective in meeting its objectives.

 Adjourning The process of ending the group, which means letting go of the group structure and moving on.

Robbins and Judge (2010), mention in their book that cross functional teams between organizations are effective for exchanging information, develop new ideas, solve problems and to coordinate complex projects. Looking at the five stages of Tuckman, Robbins and Judge (2010) mention that the early stages are often very time consuming, as members learn to work with diversity and different backgrounds with different experiences and perspectives. Leurs et al (2003) agree with this because working with an integrated care team, is built on trust but also on the fact that all participants need to understand and recognize each other‟s potential value and contributions. To realize this, trust is necessary and this is a time consuming factor.

Thus to create an effective integrated team, first everyone needs to have the same goal. Second, members need to trust each other and finally all members need to recognize each other‟s values, perspectives and contributions.

4.3 Communication

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Background

Robert F. Kroes Page 18 of 66 in an organization, people are continuously making decisions. How good these decisions are determines how much value the organization creates. To make good decisions, communication is very important. Brown, et al. (2003), agrees that integrated teams which are in their initial stage may improve by using good communication, in order to understanding and exchange information with different professional groups in the best possible way.

4.4 Project monitoring

Information and communication are important aspects in any organization, therefore modern organizations become more and more dependent on their information systems. The flow of information between all participants is crucial for carrying out an effective and efficient communication (Stefansson, 2002; Stephan et al. 2008)

Hoven (2004) mentions in his article, that modern organizations have become increasingly dependent on data, because data can be used to manage the organization. An example is knowledge about specific objects which is rooted in the skills and experiences of employees which they have accumulated in the course of their professional lives. In most companies a systematic approach of distributing this knowledge is missing and therefore stays implicit.

As mentioned above, disintegration between housing, welfare, and healthcare can be caused by the lack of an ability to evaluate and interpret changes in the organization and its environment. The purposes of implementing information systems in an organization are improving the effectiveness and efficiency of that organization (Silver et al, 1995). When looking at information systems, information systems provide a support for organizations on three levels. The first level is support for business operations, the second level is managerial decision making, and the third level supports on strategic advantage (O‟Brien, 1996). Therefore a management information system (MIS), which is a system or process that provides the information necessary to manage an organization effectively, is recommended (Comptroller‟s Handbook, 1995).

One of the greatest challenges in monitoring a project is the availability of up-to-date and accurate data. Good data provides management with information necessary to make good managerial decisions. It will also help in prioritizing tasks, assigning resources, and accurately reporting the latest status of a project. So information systems should provide up-to-date, accurate and complete data on predetermined Key Performance Indicators (KPI).

4.5 Conceptual Model

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Background

Robert F. Kroes Page 19 of 66 Figure 1: Conceptual model

The conceptual model shows that several factors are important to increase efficiency and effectiveness of welfare, housing, and healthcare services for the vulnerable elderly in Menterwolde. The goal of the project “Zichtbare schakel” is to improve welfare, healthcare, and housing for the vulnerable elderly in Menterwolde which will result in the fact that the elderly can live in their own home situation longer and that costs can be reduced. In the end this should lead to a higher level of welfare and wellbeing among inhabitants of the municipality Menterwolde.

Community nurse:

The community nurse will play a central role between the vulnerable elderly and the different welfare, housing, and healthcare providers. Locating vulnerable elderly should be done in an early stage so that the community nurse could use informal care instead of professional care. When vulnerable elderly people are located and the problems are clear, the community nurse brings the vulnerable elderly in contact with a suitable service provider (professional or informal).

Central role between parties: In the case of the community nurse, communication is important, because

the community nurse plays a central role between the elderly and all participants of the integrated collaboration that deliver welfare, healthcare and housing services. To communicate between the different parties, it is important to have the right communication tool. The communication with the vulnerable elderly should be actively and mainly verbal. Some solutions are home interviews or just a social talk. The communication with the welfare, healthcare and housing service providers should be verbal but it should also be supported by ICT solutions (Versteeg & Bouwman, 2006; Stefansson, 2002).

Prevention intervention: The purpose of the prevention intervention is to increase self-reliance by taking

early actions. There are three types of preventions: The first one is primary prevention, which are activities that prevent a specific health problem, illness or accident occurring to healthy people. In secondary prevention, diseases or abnormalities are detected and the goal of this kind of prevention is to stop the diseases or abnormalities. The last form of prevention is tertiary prevention. Tertiary prevention

Increasing prevention intervention by recognition of vulnerable elderly people at an early stage

Deploying a community

nurse in Menterwolde

Establishing an integrated collaboration between welfare, housing, and healthcare services Central role between welfare,

housing and healthcare providers and the vulnerable elderly

Increased efficiency and effectiveness of welfare, housing, and

healthcare services for the vulnerable

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Analysis

Robert F. Kroes Page 20 of 66 (often dealt by health care) is to prevent further complications or progression of a diseases or abnormality. An example is the treatment of diabetes patients in order to prevent complications or to delay the progression (RIVM, 2011). The project "Zichtbare schakel: De dorpsverpleegkundige in Menterwolde” is only looking at secondary prevention. With this form of prevention the project is aiming at coaching and improving the wellbeing and lifestyle of elderly people to make it possible for people to live in their own home environment as long as possible. When the vulnerable elderly are recognized at an early stage, the community nurse can look for possibilities other than professional care. When informal care is used, costs on the professional care can be reduced (Scheringa, 2011).

Integrate collaboration:

The public healthcare is not only about cooperation between medical and non-medical persons, but also between organizations which are often from different domains. This cooperation focuses on a wide range: from joint innovation, implementation and evaluation to achieve a new way of working together (Leurs, et al, 2003).

5 Analysis

In the analysis chapter first the current situation will be discussed based on an initial screening. After this initial screening this chapter describes how a community nurse can increase efficiency and effectiveness of welfare, housing, and healthcare service for vulnerable elderly people. Thirdly, this chapter will discuss how an integrated collaboration between welfare, housing and healthcare providers can increase efficiency and effectiveness of welfare, housing, and healthcare service for vulnerable elderly. The last section of this chapter will describe how the project “Zichtbare schakel” can be monitored.

5.1 The current situation

The project "Zichtbare schakel: De dorpsverpleegkundige in Menterwolde”, started in January 2011. After 26 months, when the grant is terminated, the project team hopes to demonstrate, through a result assessment, that the project can be marked as a success. The results can be used to find other funds that will invest in the project. To perform a result assessment the current situation needs to be analyzed in an initial screening to provide a reference point.

This initial screening which has been conducted as a part of this research can be found in appendix II.

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Analysis

Robert F. Kroes Page 21 of 66 the side of the care providers. The WMO introduces a new system for all Dutch citizens covering care and support in cases of protracted illness, invalidity or geriatric diseases (Minvws, 2009).

At the moment the community nurse is a new function next to the regular visiting nurse and the WMO consultant, which are already active in Menterwolde. This new function of community nurse is strong related to the tasks of a WMO consultant. A WMO consultant is a person who has contact with individuals who apply for a reimbursement from the WMO. This person will visit clients who apply for a new WMO application to determine if they have the right to be helped by the WMO.

Currently efficiency only increases when costs can be reduced on the support or services provided by welfare, housing, and healthcare providers. The project “Zichtbare schakel” aims to reduce costs by increasing the use of informal care and to reduce professional care. Meaning that costs will be saved by moving task or services provided by professional care to family and volunteers (informal care). To realize this, the number of people that are currently active in the informal care (approximately 1500 people) needs to be increased. This is also an important factor which needs to be handled by the community nurse.

Currently, in the Netherlands, people can choose their own healthcare provider. Some of the respondents of the interviews indicate that they are afraid that Meander will create a situation in which they have an advantage compared to their competitors. This is because Meander employs the community nurse and therefore they have direct contact with potential clients in an early stage, which they could use to influence clients to make use of their services. Meander mentioned that they are aware of this position. They state that the purpose of the project “Zichtbare schakel” is not to increase their number of clients but to realize a higher goal, which is to increase the wellbeing and welfare of the inhabitants of Menterwolde.

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Analysis

5.2 Community nurse

This part of the research will focus on the community nurse and how this person can increase the efficiency and effectiveness of welfare, housing, and healthcare services for the vulnerable elderly in Menterwolde.

5.2.1 Increasing efficiency by deploying a community nurse

The project “Zichtbare schakel” has already been launched in other cities and municipalities in the Netherlands. In most of these projects the community nurse has an important role in improving the independence and self-reliance of elderly people.

One of the most important results of these projects is that the total number of WMO applications dropped, because the community nurse encourages the use of informal care in the villages. Evidence for the reduction of WMO application can be found in the report of community nurse in Elsendorp. In 2009 the community nurse in Elsendorp received a total of 115 healthcare applications. From this total number of 115 applications only 9 applications were redirected to the WMO counter as a WMO application. This reduction was accomplished because the level of informal care in Elsendorp increased. This increase in informal care led to a 97% reduction of new WMO applications (Penninx, 2008; Bosmans, 2011). Another example can be seen in the research of Frieslab on their elderly advisor (same concept as a community nurse). This research showed that in the municipality Boarnsterhim the WMO applications dropped by 19% by deploying an elderly advisor who uses informal care in the municipality (Frieslab, 2009). These examples show that recognizing problems of vulnerable elderly in an early stage will result in smaller problems and they can use informal care for a longer period of time. This will delay the use of professional care. This is also argued by Kemper (1992). The delay of professional care results in the fact that the costs of professional care will directly be minimized because the informal care exists of volunteers.

To find out whether a reduction of new WMO applications will also benefit Menterwolde, a scenario analysis has been conducted. A scenario analysis is a process of analyzing possible future events by considering alternative possible outcomes or scenarios. This method has been chosen because of the big differences between the WMO application reduction of Elsendorp and Boarnsterhim (Elsendorp 97% and Boarnsterhim 19%). Before this research will define the different scenarios the WMO budget, number of current WMO applications and the costs of a community nurse will be determined.

The national WMO budget in the Netherlands is currently divided amongst the different municipalities based on distribution model. This model divides the total WMO budget based on age, family composition, income, occupational health needs and geographical factors (Minvws, 2009). Drese (2010) mentions in his report that the WMO budget of the municipality Menterwolde is around € 1.250.000. This WMO budget exists of three parts:

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Analysis

Robert F. Kroes Page 23 of 66 3- Overhead costs (estimated at 12% because in all financial calculation of the project “Zichtbare

schakel” they used an overhead of 12%)

The first group (existing care or support), are people and organizations that already use money from the WMO budget, use each year around 60% of the total WMO budget (Drese, 2010; Gemeente Menterwolde, 2008). When looking at the WMO budget of 2011, the budget that can be used for new applications is 40% which is around € 500.000.

The number of WMO applications in Menterwolde, in 2009, was 490 (Dooms, Lonkhuijzen, 2009). When looking at the fact that the number of people with an age above 75 will grow until 2030 with 124,2%, the number of WMO applications will probably increase as well. At the moment it is unclear by how much the WMO applications will increase. We estimate the increase of WMO applications based on the growth index of elderly people that live alone, because this is the only information about a possible growth of the WMO applications that is currently available to us. The growth index of elderly people who live alone is 20% (Kuipers et al., 2010). Based on the growth index of 20% the expectation is that the number of WMO application will be around 550 a year.

To determine the costs that can be saved on new WMO applications, this research will first look at the cost of one WMO application. To determine the costs of one new WMO application the W MO budget of “New application for care and support” needs to be divided by the number of new WMO applications. This results in an average cost of approximately € 900 per application.

Now that the WMO budget of 2011 and the number of expected WMO applications is known, the costs of a community nurse need to be defined. Table 3 shows the costs per year of a community nurse deployed with 2,5 Fte (€ 135.000). The deployment of 1 Fte will cost around 54.000 euro/year.

Personnel costs for one year

Function Gross salary % Fte # Months Salary costs Social security (37%) Gross salary costs Overhead costs (12%) Total costs Community nurse € 2.934 100% 12 € 35.208 € 13.027 € 48.234 € 5.788 € 54.023 Community nurse € 2.934 100% 12 € 35.208 € 13.027 € 48.234 € 5.788 € 54.023 Community nurse € 2.934 50% 12 € 17.604 € 6.513 € 24.117 € 2.894 € 27.011 Total costs € 135.057

Now that the costs of a community nurse and the WMO budget are known, the different scenarios can be defined based on assumptions concerning the future of informal care and the future of the WMO budget.

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Analysis

Robert F. Kroes Page 24 of 66 Scenario 1- No change in informal care and the WMO budget stays the same as in 2011:

After the deployment of a community nurse in Menterwolde this first scenario assumes that people are not willing to help each other. People start to think why they should help someone when there is a community nurse that can help vulnerable elderly people. In this scenario there will be no changes in the level of informal care. This will result in the fact that there will be no reduction of new WMO applications. In this scenario the WMO budget will still be € 1.250.000, which is the same as the budget of 2011.

Scenario 2 - High use of informal care and the WMO budget stays the same as in 2011:

In this scenario the use of a community nurse increases the social cohesion in the villages of Menterwolde, which causes that a lot of people are willing to help each other. This will lead to the fact that informal care increases and the number of new WMO applications will reduce with 75%. Also in this scenario the WMO budget stays the same for the next few years (€ 1.250.000).

Scenario 3 - Low use of informal care and the WMO budget stays the same as in 2011:

After the deployment of a community nurse in Menterwolde the level of informal care increases but only with a small percentage. This will cause a lower reduction on new WMO applications than in the second scenario. In this scenario the assumption is that the WMO reduction of new applications is 15%. Also for this scenario the WMO budget stays the same.

Scenario 4 - No change in informal care but the WMO budget will decrease

In this scenario there are no changes in the level of informal care and in the number of new WMO applications. Only the WMO budget will be reduced with 20% to € 1.000.000. This scenario is chosen because the municipality mentions in its annual budget report that there is the risk that coming years the WMO will be reduced (Programma begroting 2011).

Scenario 5 - High use of informal care but the WMO budget will be reduced:

This fifth scenario will have the same high level of informal care as the second scenario. This causes a reduction of 75% on new WMO applications. In this scenario the WMO budget will also be reduced by 20%.

Scenario 6 - Low use of informal care and a reduction on the WMO budget:

This last scenario means a low level of informal care which causes a small reduction in the number of new WMO applications (only 15%). Also this scenario needs to deal with the same reduction to the WMO budget as the scenarios four and five (20%) which means that the WMO budget is € 1.000.000.

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Analysis

Sc ena ri o Sc ena ri o’ s WMO budget Level of informal care Reduction new WMO applications # WMO applicati ons saved Costs saved on WMO applications Costs of community nurse Total costs saved by the project 1 € 1.250.000 Current 0% 0 € 0 € 135.000 -€ 135.000 2 € 1.250.000 High 75% 380 € 350.000 € 135.000 € 215.000 3 € 1.250.000 Low 15% 80 € 75.000 € 135.000 -€ 60.000 4 € 1.000.000 Current 0% 0 € 0 € 135.000 -€ 135.000 5 € 1.000.000 High 75% 410 € 300.000 € 135.000 € 165.000 6 € 1.000.000 Low 15% 80 € 60.000 € 135.000 -€ 75.000 Table 4: Scenario analysis community nurse

It is clear that the level of vulnerable elderly people that use informal care is very important for the balance of the costs versus the benefits of a community nurse. This scenario analysis shows that when informal care increases, costs are transferred from professional care to informal care. Meaning that the volunteers take over the work that is normally done by professionals. This will lead to the fact that people who are helping in the informal care, indirectly pay for the costs savings by doing volunteers work. Based on these calculations it can be concluded that the success of the project ”Zichtbare schakel” does not only depend on the number of people that need help, but it also depends on how much work can be done by informal care instead of professional care.

To calculate the breakeven point, where the number of reduced WMO applications cover the cost of the community nurses ( 2,5 Fte), this research uses the following steps. First the average costs per WMO application needs to be calculated by dividing the total WMO budget for new applications by the number of expected applications. When the average cost of one WMO application is known, the total cost of a community nurse will be divided by this average cost of one WMO application. This way the breakeven point is calculated which shows with how much the WMO applications in one year should be reduced to cover the costs of 2,5 Fte of the community nurse.

Total WMO budget = € 1.250.000

WMO budget new applications (40%) = € 500.000 Number of expected applications = 550 per annum

Average cost of one WMO application = € 500.000 / 550 ≈ € 900

Cost community nurse (2,5 Fte) = € 135.000

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Analysis

Robert F. Kroes Page 26 of 66 The breakeven point shows that to cover all the costs of a community nurse, a reduction of 90 new WMO applications should be realized. This means a reduction of 25%. When calculating the breakeven point if the WMO budget decreases with 20% (WMO budget of € 1.000.000), the number of saved WMO applications needs to be around 190. This means a reduction of 35%.

In the WMO monitor Menterwolde an estimation has been made about the number of people that are currently active in the informal care. This number currently lays around 1500 people. When the community nurse wants to achieve a reduction of 75% WMO applications the number of people that are involved in the informal care needs to grow. This growth index depends on the kind of applications that are received but also on the tasks and services people in the informal care can provide. The main thing is to increase the use of informal care by recognizing the vulnerable elderly in an early stage because problems at that time will be smaller and often more easy to deal with. Also, the informal care can be used for a longer period of time. This will then delay the use of professional care (Kemper, 1992). Other researches (Schreuder-Goedheijt & Visser, 2003; Timmers, Paes & Penninx-Donkers, 2010; Bosmans, 2011) show that informal care increases when the there is a high level of social cohesion in the villages. Based on the report of Schreuder-Goedheijt, Visser and Huijberegts (2006), a community nurse could increase the social cohesion in the different villages by showing the people the opportunities and benefits that the Dutch government has for people who are active in the informal care.

These results show that costs can be reduced when informal care takes over the services of professional care. However this is only possible when the community nurse can increase the use of informal care and support. By increasing informal care, it will lead to a reduction in the amount of new WMO applications. Therefore another benefit is that the workload for a WMO consultant will reduce. The advice here would be to increase the efficiency by combining the functions of the WMO consultant and the community nurse into one function. This way the community nurse could take over the tasks of the WMO consultant, which are (tempo-team, 2009):

 Processing WMO applications.

 Examine whether the application is legitimate and set an indication for application.

 Plan home visits to assess the application.

 Communicate with external parties about decisions.

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Analysis

Robert F. Kroes Page 27 of 66 take over the control and responsibility of the community nurse. This way the problem that some of the respondents mentioned, namely that the community nurse will create an advantage position for Meander, could be solved. When the municipality Menterwolde is in control of the community nurse, the community nurse will be neutral. The municipality does not have any interest in which service providers will be used, their only interest is to provide good living conditions and the possibility to make sure that people can live as long as possible in their own environment. Another benefit for the municipality is mentioned in the report of Omring (2010). They mention that when the municipality and the community nurse join forces, the community nurse could help the municipality in their development of a local health policy because she has local knowledge of the district in terms of care and welfare. Unfortunately it won't be easy to put the municipality Menterwolde in charge of the community nurse, because the municipality is not sure whether it wants to join the project.

Not only can the WMO benefit from the project “Zichtbare schakel” also other parties can gain benefits by the use of a community nurse (Omring, 2010). One of these parties are the general practitioners, because general practitioners have a long standing wish to have a contact person in the villages which will act as a clear and relevant expertise point, who knows chain partners and the people in the villages. This would lead to the fact that general practitioners could use the community nurse to visit clients that need extra attention. In the end the general practitioners will spend less time on house visits which leads to a reduction in costs. At the moment it is not clear how much cost can be saved for the general practitioners in Menterwolde, because they are not involved in this research.

After talking with the general practitioner of the village „t Zandt which is located in the North of Groningen, it became clear that some general practitioners make a lot of house visits and others much less. The general practitioner in “t Zandt mentioned that an average house visit costs around 30 minutes and that he visits around four patients a week. The rest of his clients come to his practice. Using this information the general practitioner visits around 150 clients a year. When estimating that 70% of these visits can be transferred to the community nurse, a general practitioner can transfer 100 house visits to the community nurse which saves the general practitioner around 50 hours a year. In the case of Menterwolde there are five general practitioners. Based on this the expectation of the total hours that can be saved on the general practitioners is around 250 hour a year. This estimation has been calculated on the experiences of the general practitioner in „t Zandt because it was a constraint of this research that the general practitioners in Menterwolde could not be involved in this research.

5.2.2 Increasing effectiveness by deploying a community nurse

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Analysis

Robert F. Kroes Page 28 of 66 where they can go to when they have problems. Also the use of a community nurse will result in the fact that social relations between inhabitants stay intact, which helps to promote overall health and welfare of the people but this can lead to a higher level of informal care.

In Amsterdam, general practitioners mentioned that the concept of the community nurse who does the house visits, monitors, and helps vulnerable elderly people will increase the living conditions of vulnerable elderly. This is because the community nurse helps to finds suitable solutions for problems like taking medicines or helping with groceries. Also the community nurse increases the trust between elderly and professionals which eventually results in lower costs for professional care because the elderly will contact general practitioners sooner when they have mental problems. This way problems are recognized in an early stage which will lead to the fact that problems are smaller. (Rijksoverheid, 2011).

5.3 Integrated collaboration of welfare, housing and healthcare

This part of the analysis will focus on the integrated collaboration between welfare, housing, and healthcare providers and how this, together with the central role of the community nurse, can increase the efficiency and effectiveness of welfare, housing, and healthcare services for vulnerable elderly people in Menterwolde. In the first section this paragraph will look at the efficiency that can be realized and the second part will look at the effectiveness of an integrate collaboration.

To analyze the possibilities of an integrated collaboration this research looks at the multifunctional center the Gilde, because the Gilde uses an integrated team of welfare, housing, and healthcare services, to support the people that live in the Gilde.

5.3.1 Increasing efficiency with an integrated collaboration

In the public healthcare it is not just about cooperation between professionals (doctors and non-medical persons), but also about the cooperation between organizations in different domains (Leurs, et al, 2003). One of the objectives of the project “Zichtbare schakel” is, to create an integrated welfare, housing, and healthcare collaboration at the municipality level. In this collaboration the community nurse will play a central role, she will connect the vulnerable elderly to a suitable partner(s).

With the interview in Appendix III, this research also looked at the collaboration between the different partners in the Gilde. The current cooperation between the different partners is very positive, the average grade that is given to the cooperation, on a scale from 1 (very bad) to 10 (very good), is a 7.3.

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Analysis

Robert F. Kroes Page 29 of 66 problems are solved quicker. This is the result of the fact that partners ask each other for suggestions, help, and solutions. When problems are solved quicker, time can be reduced. At the moment it is difficult to say how much money will be saved, because problems are never the same. The expectation is that the short communication lines between welfare, housing and healthcare providers will minimize costs because problems can be solved quickly. This benefit of short communication lines is also recognized by Woittiez, et al (2009).

Another point that will increase the efficiency is the central role of the community nurse in the integrated collaboration. This central role means that not every partner in the integrated collaboration needs to do general client-administrative work. For example if the community nurse registers the name, date of birth, mental or physical problems, and whether there is an indication for this client other parties can use this information for their own (client) registration. This way general information about clients can be shared. This can reduce costs, especially when a client uses several service providers. For example if a client receives care by two healthcare organizations, both need to register general information. This intake will consume time and therefore it costs money. By avoiding that both need to do an intake and that only the community nurse will contact the client, it will not only create a clearer situation for the client but also time can be saved by both healthcare organizations.

5.3.2 Increasing effectiveness with an integrated collaboration

The project “Zichtbare schakel” wants to establish an integrated team of welfare, housing, and healthcare providers. Their goal would be to increase the wellbeing and living conditions of vulnerable elderly people and to keep them in their own familiar environment as long as possible. A study done by the NPO shows that people that live in the Gilde are people that need a high level of care, but this does not seem to cause any problems concerning their wellbeing. People in the Gilde stated that they like their lives and that they experience a high level of wellbeing (NPO Screening, 2011). Based on this, the results of the Gilde are not only positive for the different partners but also for the people who are living in the Gilde. That the integrate collaboration in the Gilde provides positive aspects, can also be linked to the fact that Gilde wants to change its status of a project to a platform status. This way the Gilde can be a model for other projects.

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Analysis

Robert F. Kroes Page 30 of 66 In the integrated collaboration in the Gilde the communication lines are short, not only on the professional level but also on the social level. An example is the activities organized for people within and outside the Gilde. These activities are often organized by several partners which show that the cooperation goes beyond the area of healthcare. The activities are organized in order to increase the wellbeing of the people in the Gilde. These activities are based on increasing the social level of people. Some examples are card games, bingo, eating and drinking together and all kinds of other activities.

This research shows that the Gilde is a good example of integrated care at the local level of Muntendam. For the future the same should be realized for the municipality Menterwolde by using the Gilde as a guideline.

5.4 Monitoring the project

The idea is to monitor the project “Zichtbare schakel: De dorpsverpleegkundige in Menterwolde” during the 26 months that the project runs. This way problems and other difficulties can be solved during the project to increase the success of the project. This paragraph tries to find a suitable method to monitor the project. The first section describes why use an information management system. The second section will describe the possibilities of a balance scorecard. The third section discusses the purpose of a management dashboard. The fourth section describes which system to use followed by the fifth section about the design criteria‟s for the management dashboard. The final section shows what the management dashboard will look like for this project.

5.4.1 Information management

Modern management systems are covered with business intelligence tools in combination with databases. In these databases, data from the organization is collected en will be combined as management information. The problem is that the data in a database can be complex, therefore business intelligence is used to reduce the complexity and to provide managers with usable information (Kennisportaal, 2011).

In case of this project, management needs to know whether the project is on track and whether the expected results are achieved. To do this information needs to be collected in a database. To provide this data to the management, a business intelligence tool needs to be used. How this business intelligence tool needs to look like depends on what management wants. In this case the project team wants to have one overview of all important data. From interviews with the project leader, the key performance indicators (KPI‟s) that should be shown are:

 The number of elderly people that are visited by the community nurse

 The number of households that are visited

 Results from the prevention interventions

 Number of WMO applications

“Zichtbare schakel: De dorpsverpleegkundige in Menterwolde”

A better link between housing, welfare, and

healthcare at district level

“Zichtbare schakel: De dorpsverpleegkundige in Menterwolde”

A better link between housing, welfare, and

healthcare at district level

“Zichtbare schakel: De dorpsverpleegkundige in Menterwolde”

Preface

Management Summary

Table of Contents

Glossary

1 Introduction

1.1 The municipality Menterwolde

1.2

The project “zichtbare schakel”

1.3 Vulnerable Elderly

1.4 Professional vs. formal care

1.5 Initial Motive

1.6 Research Goal

2 Problem definition

2.1 Research Question

2.2 Sub-Questions

2.3 Constraints

3 Research approach

4 Background

4.1 Self-reliant

4.2 Integrated collaboration

4.3 Communication

4.4 Project monitoring

4.5 Conceptual Model

5 Analysis

5.1 The current situation

5.2 Community nurse

5.2.1 Increasing efficiency by deploying a community nurse

5.2.2 Increasing effectiveness by deploying a community nurse

5.3 Integrated collaboration of welfare, housing and healthcare

5.3.1 Increasing efficiency with an integrated collaboration

5.3.2 Increasing effectiveness with an integrated collaboration

5.4 Monitoring the project

5.4.1 Information management